Patient Benefits Representative

Patient Benefits Representative

Under general supervision, the Patient Benefits Representative educates patients regarding insurance coverage and benefits; assesses patients' financial ability; and may develop payment plans or recommend assistance programs when appropriate. The role registers and supports patients, verifies insurance and eligibility information, obtains required authorizations and referrals, explains financial obligations, collects and processes patient payments, maintains accurate account and insurance records, and supports timely claim submission and resolution. The Patient Benefits Representative also prepares and reviews reimbursement and liability forms, coordinates with clinical, front-office, billing, payer, and community resources, and performs assigned administrative and financial duties in accordance with HIPAA, the Code of Ethics and Business Standards, and applicable policies and procedures.

Responsibilities include reviewing patient information before appointments; obtaining, verifying, and entering current demographic, insurance coverage, eligibility, and benefit information accurately and timely in the applicable system. They also register patients and maintain complete, accurate patient and account records throughout the course of treatment. They educate patients and families about insurance coverage, benefits, co-pays, deductibles, out-of-pocket responsibilities, coverage limitations, and other financial obligations using clear and appropriate terminology.

They assess patients' ability to meet treatment-related expenses; discuss payment options; establish financial arrangements when necessary; and document agreed-upon arrangements. They identify potential coverage gaps and assist patients with applications for public assistance, financial assistance, pharmaceutical or charitable aid programs, and other available community resources. They collect co-pays, deductibles, outstanding balances, and other required patient payments; issue or maintain appropriate supporting documentation; and prepare deposits for the bank when needed.

They review patient account balances and insurance status before treatment; obtain and document required pre-authorizations, approvals, referrals, eligibility confirmations, and procedure or billing codes. They review insurance, reimbursement, and liability forms with patients; obtain required signatures; verify completeness; and forward appropriate information and forms to the billing office. They ensure relevant front-office staff understand carrier requirements, current insurance information, and authorization or referral requirements that affect patient services.

They run and review reports to confirm allowed services, remaining benefits, authorization status, and other information needed to support treatment and billing. They provide correct diagnosis, procedure, billing, and insurance information to support clean claim submission and accurate reimbursement. They submit claims and required supporting documentation for payment; monitor aging and outstanding accounts; research and resolve claim delays or denials; and resubmit claims or payer correspondence as needed to expedite payment.

They follow up on collection issues, payer requests, and unresolved account activity; maintain documentation of actions taken and communicate status to appropriate internal partners. They review and reconcile explanations of benefits and related remittance information; identify discrepancies; and coordinate corrections or follow-up as appropriate. They process refunds, reimbursements, overpayments, account adjustments, and other financial transactions in accordance with established procedures and authorization requirements.

They update patient demographics, insurance coverage, benefits, and financial information in the computer system according to standard operating procedures and internal controls. They coordinate with providers, clinical staff, billing personnel, payers, co-workers, and office-site personnel to resolve benefit, authorization, coding, billing, and patient-account questions. They maintain proficiency with electronic medical records, payer portals, office systems, and job-related software; use sound judgment when handling detailed financial and clinical-administrative information.

They maintain confidentiality of patient and employee information and comply with HIPAA, privacy and security requirements, the Code of Ethics and Business Standards, and all applicable policies, laws, and regulations. They perform other duties as requested or assigned.

Qualifications include a high school diploma or equivalent required. Minimum of three years of experience as a patient pre-services coordinator or in an equivalent patient benefits, insurance verification, financial counseling, or revenue-cycle support role. Proficiency with computer systems and Microsoft Office, including Word and Excel. Proficiency with medical terminology, insurance terminology, coding applications, and the correct use of terminology in patient, payer, provider, and billing communications. Ability to work accurately with detailed financial, demographic, insurance, and patient-account information. Ability to communicate clearly and professionally with patients, families, co-workers, providers, payers, and external resources. Successful completion of required e-learning courses within 90 days of assuming the position.

Core competencies include technical and functional expertise, planning and adaptability, continuous improvement, work commitment, and customer and patient focus.

The physical demands described are representative of those required to perform the essential functions of the position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to handle or feel; and talk or hear. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift or move up to 40 pounds. Specific vision abilities include close vision and the ability to adjust focus. Corrected vision and hearing within the normal range are required.

Work is performed in an office environment with frequent interaction with patients and staff. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations, and other conditions common to an oncology or hematology clinic environment. Minimal travel by automobile between office sites may be required. Interaction with co-workers and management may occur in person and through electronic systems.